ACP InternistWeekly

In the News for the Week of March 5, 2013

Highlights

Tests do little to reassure patients who likely didn't need them

Patients who receive diagnostic tests for the purpose of reassurance don't feel less worried in either the short or long term,
a meta-analysis found. More...

Afib associated with cognitive impairment, dementia regardless of stroke history

Atrial fibrillation (AF) was associated with a higher risk for cognitive impairment and dementia, with or without a history
of clinical stroke, a meta-analysis found. More...

Test yourself

MKSAP Quiz: 2-year history of daytime somnolence, snoring, and apnea

A 65-year-old man is evaluated for a 2-year history of daytime somnolence, snoring, and apneic episodes during the night as
witnessed by his wife. He does not have blurred vision, tinnitus, or headache. He has no cardiopulmonary symptoms and does
not smoke cigarettes. The patient has hypertension for which he takes lisinopril and atenolol. Following a physical exam and
lab studies, what is the most appropriate management? More...

Quality of care

Study analyzes diagnostic errors in primary care

Diagnostic errors in primary care are often related to process breakdowns during the clinical encounter, according to a new
study. More...

Cardiology

Increased walking impairment linked to higher mortality risk in PAD

Patients with peripheral arterial disease (PAD) whose walking ability decreased over a two-year period had a higher risk for
death, a new study found. More...

FDA update

Peginesatide pulled from the market

All lots of the injectable anemia drug peginesatide (Omontys) have been recalled, due to new postmarketing reports of serious
hypersensitivity reactions, some fatal. More...

From Annals of Internal Medicine

CME credits available in patient safety supplement

A supplement to the March 5 Annals of Internal Medicine, which offers 11 CME credits, focuses on a recent Agency for Healthcare Research and Quality–funded project, "Making
Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices." More...

Internal Medicine 2013

ACP to conduct Annual Business Meeting

All members are encouraged to attend ACP's Annual Business Meeting to be held during Internal Medicine 2013. Current College
Officers will retire from office and incoming Officers, new Regents and Governors-elect will be introduced. More...

From the College

ACP and MGMA-ACMPE collaborate on online cost survey

ACP and MGMA-ACMPE are working together to provide physicians an opportunity to participate in an exciting new streamlined
MGMA 2013 Cost Survey. More...

Vote for your favorite entry

Highlights

Tests do little to reassure patients who likely didn't need them

Patients who receive diagnostic tests for the purpose of reassurance don't feel less worried in either the short or long term,
a meta-analysis found.

To study the effect of diagnostic tests on worry about illness, anxiety, symptom persistence, and subsequent use of health
care resources in patients with a low pretest probability of serious illness, researchers conducted a systematic review and
meta-analysis of 14 randomized, controlled trials that included 3,828 patients.

Three trials showed no overall effect of diagnostic tests on illness worry (odds ratio [OR], 0.87; 95% CI, 0.55 to 1.39),
and two showed no effect on nonspecific anxiety (standardized mean difference, 0.06; 95% CI, −0.16 to 0.28). Ten trials
showed no overall long-term effect on continuation of symptoms (odds ratio, 0.99; 95% CI, 0.85 to 1.15). After excluding outliers,
the authors found the suggestion of a reduction in visits after conducting tests (OR, 0.77; 95% CI, 0.62 to 0.96). Researchers
noted that the number of patients needed to test to avoid one subsequent visit varied from 16 to 26, depending on the symptom.

They concluded, "In the context of widespread belief that diagnostic testing reassures patients, these findings suggest that
physicians overestimate the value of testing when the probability of serious disease is low." They added that the reassurance
of a negative test offers comfort that can last as little as a few hours—"a fleeting sense of relief"—instead
of long-term assurance.

An editorial noted that if it requires testing 16 to 26 patients to avoid one repeat visit, and the tests cost $250 to $500 per test, then
the health care system is spending between $4,000 and $16,000 to prevent a $100 primary care visit.

The editorial offered five suggestions:

Order diagnostic tests based on greater anxiety, symptom persistence or complexity;

Don't assume patients want more testing;

Offer reassurance through written or verbal information on the meaning of normal results;

Develop evidence-based guidelines for diagnostic testing for common conditions; and

Afib associated with cognitive impairment, dementia regardless of stroke history

Atrial fibrillation (AF) was associated with a higher risk for cognitive impairment and dementia, with or without a history
of clinical stroke, a meta-analysis found.

Twenty-one studies were included in the meta-analysis, seven that looked at the association of AF with cognitive impairment
or dementia after stroke and 14 that examined the association between AF and cognitive impairment or dementia in a broader
population, including patients with or without a history of stroke.

In a combined analysis, AF was significantly associated with cognitive impairment (relative risk [RR], 1.40; 95% CI, 1.19
to 1.64). There was significant heterogeneity among studies, mainly from variability among prospective studies and possibly
due to variances in outcome measures. So researchers incorporated a random-effects model and did several sensitivity analyses
and found that pooled estimates were virtually the same for prospective and cross-sectional studies. Restricting the analysis
to studies of dementia, which is more reliably diagnosed than cognitive impairment, eliminated the significant heterogeneity
without changing the pooled estimate substantially (RR, 1.38; 95% CI, 1.22 to 1.56).

Limiting the analysis to the eight studies that defined cognitive impairment as a mini-mental state exam (MMSE) score of 24
or less or cognitive decline as a reduction in MMSE score of 3 points or more did not appreciably change the results (RR,
1.38; 95% CI, 1.11 to 1.71). Investigating subtypes of dementia did not reveal any significant association between AF and
Alzheimer's disease (RR, 1.22; 95% CI, 0.96 to 1.56); however, the association was significant for vascular dementia (RR,
1.72; 95% CI, 1.27 to 2.32).

Limiting the analysis to participants without a history of stroke and studies that adjusted for stroke in multivariate analyses
did not appreciably affect the primary results (RR, 1.34; 95% CI, 1.13 to 1.58), nor did restricting the analysis to studies
that specifically excluded patients with a history of stroke (RR, 1.37; 95% CI, 1.08 to 1.73).

The researchers wrote, "On the basis of this systematic review and meta-analysis of all available data, future research should
carefully distinguish between types of dementia, and investigators should consider cognitive function as a new outcome to
be assessed in interventional studies for the treatment of AF."

Test yourself

MKSAP Quiz: 2-year history of daytime somnolence, snoring, and apnea

A 65-year-old man is evaluated for a 2-year history of daytime somnolence, snoring, and apneic episodes during the night as
witnessed by his wife. He does not have blurred vision, tinnitus, or headache. He has no cardiopulmonary symptoms and does
not smoke cigarettes. The patient has hypertension for which he takes lisinopril and atenolol.

On physical examination, temperature is normal, blood pressure is 170/98 mm Hg, pulse rate is 72/min, and respiration rate
is 18/min. BMI is 44. Oxygen saturation is 95% with the patient breathing ambient air and does not decrease with modest exertion.
The patient's face is erythematous, and his neck is thick. Hepatosplenomegaly is absent.

Quality of care

Study analyzes diagnostic errors in primary care

Diagnostic errors in primary care are often related to process breakdowns during the clinical encounter, according to a new
study.

Researchers reviewed medical records of diagnostic errors at two sites, an urban Veterans Affairs facility and an integrated
private health care system. The errors were detected by triggers in the electronic health record due to unexpected return
visits after a first primary care visit between Oct. 1, 2006, and Sept. 30, 2007. The study's objective was to examine the
diseases, diagnostic processes, and contributing factors involved in the errors. Main outcome measures were presenting symptoms
at the initial visit, types of missed diagnoses, process breakdowns, possible contributing factors and potential harm. Results were published online Feb. 25 by JAMA Internal Medicine.

Process breakdowns were most common during the clinical encounter between the patient and the clinician providing primary
care (78.9%) but were also seen in the referral process to other clinicians (19.5%), follow-up and tracking of diagnostic
information (14.7%), and performance and interpretation of diagnostic tests (13.7%); patient-related factors, such as provision
of inaccurate medical information or problems with effective communication, were involved in 16.3%. More than one of these
types of breakdowns was involved in 43.7% of the errors. Breakdowns during the clinical encounter most commonly occurred during
the history taking (56.3%), examination (47.4%), or process of ordering further diagnostic tests (57.4%). In addition, 81.1%
of cases had no differential diagnosis noted at the initial visit, and previous progress notes were copied and pasted into
the index visit notes in 7.4% of cases. Moderate to severe harm was considered possible as a result of most of the errors.

The authors noted that their study was retrospective and that their results may not apply to primary care practices outside
integrated health systems, among other limitations. However, they concluded that diagnostic errors in the primary care setting
affected a variety of common diseases and could cause significant harm. They pointed out that most of the breakdowns occurred
during the clinical encounter, when clinicians have increasingly become more and more pressed for time.

"Our findings highlight the need to focus on basic clinical skills and related cognitive processes (eg, data gathering within
the medical history and physical examination and synthesis of data) in the age of increasing reliance on technology and team-based
care to improve the health care system," they wrote. They called for preventive interventions that target common contributing
factors, including data gathering and synthesis during the clinical encounter.

An accompanying editorial noted that while important lessons have been learned about diagnostic errors, it is difficult to determine effective solutions.
The editorialists noted that generic strategies to reduce errors have not successfully improved patient outcomes. Hybrid fixes
may be the best goal, they said, including modifying electronic health record systems so that they can continuously monitor
diagnostic performance and provide timely, specific feedback.

"One critical step toward this last approach would be mandatory, structured recording and coding of presenting symptoms, rather
than simply diagnoses, in our electronic health record systems," the editorialists wrote. "This step alone, if consistently
performed, would radically transform our ability to track and reduce diagnostic errors." The editorialists called for all
stakeholders to commit to improving diagnostic safety and quality as a top priority.

Cardiology

Increased walking impairment linked to higher mortality risk in PAD

Patients with peripheral arterial disease (PAD) whose walking ability decreased over a two-year period had a higher risk for
death, a new study found.

Researchers asked men and women with PAD to complete the Walking Impairment Questionnaire (WIQ), a self-administered questionnaire
specific to PAD, at baseline and again at two-year follow-up. The study aimed to determine whether increased decline in WIQ
stair-climbing, distance or speed scores was associated with increased all-cause and cardiovascular disease mortality rates.
Data on two-year changes in these variables were examined using Cox proportional hazards models and were adjusted for covariates
including age, sex, race, ankle brachial index, body mass index, smoking and comorbid conditions. The study results were published March 5 by the Journal of the American College of Cardiology.

Overall, 442 men and women participated in the study. One hundred twenty-three (27.8%) died during a median of 4.7 years after
the two-year follow-up assessment. Of these, 45 (36.6%) died of cardiovascular disease and 11 (8.9%) died of unknown causes.
Older age was associated with the greatest decline in the two-year stair-climbing score, while more physical activity at baseline
was associated with the greatest decline in distance score. The mean two-year score changes were −0.79, −1.78
and −1.55, respectively, for stair-climbing, distance and speed. Patients were followed for a median of 44.7 months
for cardiovascular death.

After the data were adjusted for covariates, all-cause mortality was higher in patients whose WIQ score decreased 20 points
or more over two years (hazard ratios, 1.93 [95% CI, 1.01 to 3.68] for stair climbing, 2.34 [95% CI, 1.15 to 4.75] for distance,
and 3.55 [95% CI, 1.57 to 8.04] for speed) compared with patients whose score improved by 20 points or more. Patients whose
distance score decreased by 20 points or more during the two-year period had higher cardiovascular disease mortality rates
than those whose distance scores improved by 20 points or more (hazard ratio, 4.56 [95% CI, 1.30 to 16.01]).

The authors acknowledged that their results may not be generalizable to all patients with PAD and that unidentified characteristics
may have affected their findings, among other limitations. However, they concluded that patients whose WIQ scores decrease
over time are at greater risk for all-cause mortality. "Further study is needed to determine whether implementing measurement
of two-year change in WIQ scores in clinical practice is associated with improved outcomes," they wrote.

FDA update

Peginesatide pulled from the market

All lots of the injectable anemia drug peginesatide (Omontys) have been recalled, due to new postmarketing reports of serious hypersensitivity reactions, some fatal.

To date, fatal reactions have been reported in approximately 0.02% of patients following the first dose of intravenous administration,
according to an FDA alert. The reported serious hypersensitivity reactions have occurred within 30 minutes after such administration
of the drug. There have been no reports of such reactions following subsequent doses or in patients who have completed their
dialysis session.

More than 25,000 patients have received the drug, and hypersensitivity reactions have been reported in approximately 0.2%,
with about a third of these categorized as serious, including anaphylaxis requiring prompt medical intervention and in some
cases hospitalization.

The drug should be returned to the manufacturers, Affymax and Takeda, the FDA said.

From Annals of Internal Medicine

CME credits available in patient safety supplement

A supplement to the March 5 Annals of Internal Medicine, which offers 11 CME credits, focuses on a recent Agency for Healthcare Research and Quality–funded project, "Making
Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices."

The project leaders identified 41 patient safety strategies and conducted reviews of many of them. Ten of the reviews are
included in the Annals supplement:

Each review has an accompanying CME quiz, and by completing these quizzes, physicians can earn 11 CME credits that meet professional
responsibility and risk management requirements.

In addition, the March 5 issue includes Annals' first article in "graphic novel" format, which also deals with a patient safety issue, a missed diagnosis that haunts a physician throughout
his professional life.

Internal Medicine 2013

ACP to conduct Annual Business Meeting

All members are encouraged to attend ACP's Annual Business Meeting to be held during Internal Medicine 2013. Current College
Officers will retire from office and incoming Officers, new Regents and Governors-elect will be introduced.

The meeting will be held at the Moscone Center in San Francisco on Saturday, April 13, from 12:45 p.m. to 1:45 p.m., with
outgoing ACP President David L. Bronson, MD, FACP, presiding. Dennis R. Schaberg, MD, MACP, will present the Annual Report
of the Treasurer.

A key feature of the meeting is the presentation of ACP's priorities for 2013-14 by Executive Vice President and Chief Executive
Officer Steven E. Weinberger, MD, FACP. Members will have the opportunity to ask questions following Dr. Weinberger's presentation.

From the College

ACP and MGMA-ACMPE collaborate on online cost survey

ACP and MGMA-ACMPE are working together to provide physicians an opportunity to participate in an exciting new streamlined
MGMA 2013 Cost Survey.

The survey gathers financial and other data that can help with managing costs, comparing physician and staff compensation,
optimizing clinician and office staffing and managing practice finances. Participants in the survey will receive a free report
comparing their own practice to benchmarks of their peers.

Your participation in this influential survey will make a difference to your ACP peers and the industry. Historically, internal
medicine and small practices have been under-represented, and your participation can help to ensure that reliable benchmarks
can be provided. The survey deadline is April 19. To participate, go online.

If you have questions, please contact MGMA's Data Solutions toll-free at 877-275-6462, ext. 1895, or by e-mail.

MKSAP Answer and Critique

The correct answer is B) Order sleep study. This item is available to MKSAP 16 subscribers as item 25 in the Hematology and
Oncology section.

MKSAP 16 released Part A on July 31, 2012, and Part B on Feb. 1, 2013. More information is available online.

This patient requires a sleep study to diagnose obstructive sleep apnea and nocturnal oxygen desaturation as a cause of secondary
erythrocytosis. The diagnosis of secondary erythrocytosis is suggested by the elevated hemoglobin concentration and elevated
erythropoietin level. In patients with polycythemia vera (PV), the erythropoietin level is suppressed. The most common cause
of secondary erythrocytosis is hypoxic pulmonary disease. However, this patient's oxygen saturation is normal at rest and
following modest exertion. Nocturnal oxygen desaturation due to obstructive sleep apnea is also a cause of secondary erythrocytosis,
and this diagnosis is suggested by his snoring, obesity, and increased neck size, as well as his witnessed apneic episodes.
If obstructive sleep apnea is confirmed by polysomnography, the patient's management would include continuous positive airway
pressure.

PV is characterized by nonspecific symptoms including tinnitus, blurred vision, headache, and more specific symptoms including
generalized pruritus that often worsens after bathing, erythromelalgia (a burning sensation in the palms and soles possibly
caused by platelet activation), and splenomegaly, none of which are present in this patient. In addition, his leukocyte and
platelet counts are not elevated as they often are in PV, and his elevated erythropoietin level essentially excludes PV. Treatment
of PV is directed toward reducing the red blood cell mass and preventing thrombosis. Therapeutic phlebotomy and low-dose aspirin
is the primary therapy for most patients. Hydroxyurea is often used in older symptomatic patients whose disorder cannot be
controlled with phlebotomy and aspirin alone. Because this patient does not have PV, phlebotomy, low-dose aspirin, and hydroxyurea
are not indicated.

An increased number of megakaryocytes and a hypercellular bone marrow are characteristic of PV, but bone marrow findings are
not part of the Polycythemia Vera Study Group diagnostic criteria. Furthermore, although a hypercellular bone marrow is likely
in a patient with secondary erythrocytosis, this finding does not establish the cause of the condition.

Test yourself

A 24-year-old woman undergoes routine evaluation. She is pregnant at 12 weeks' gestation. Medical history is notable for homozygous sickle cell anemia (Hb SS). She has had multiple uncomplicated painful crises treated at home with hydration, nonopioid analgesia, and incentive spirometry. Following a physical exam and lab studies, what is the most appropriate management?

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